Ideas of Reference: Apparently, That's What They Always Say!

The following is a case study from the DSM-III-R Casebook published by the American Psychiatric Association. The lead author is Robert Spitzer, M.D., Columbia University Medical School Department of Psychiatry. The case is titled "Crimes Against the State." It concerns the case of a political dissident in the former Soviet Union who was detained in a psychiatric hospital because his writings were critical of the Soviet regime. The Soviet psychiatrist notes that the dissident exhibited "ideas of reference." My former employer, the law firm of Akin, Gump, Strauss, Hauer & Feld justified its job termination decision in my case in October 1991 on the grounds that I exhibited "ideas of reference."

Crimes Against the State

Gregor, a 40-year-old economist, is brought to the maximum security ward of the Moscow Central Institute for Forensic Psychiatry from the KGB prison. Four months earlier, while searching the house of a friend, the KGB agents discovered a book, written by Gregor, that was critical of the Soviet economic system. In this book Gregor defined himself as a "Marxist economist" and a patriot of his country. He used language indistinguishable from that of the "official" and "approved" concepts current in Soviet economic and political thought. However the book is an impassioned argument for reform of the state economy in order to bring about greater prosperity and economic stability in the country.

Gregor was arrested and charged with "antigovernment propaganda and agitation harmful to the interests of the Socialist state." Because he was uncooperative during his detention, he has now been referred for a psychiatric evaluation by a KGB investigator, who writes in the referring document that "There are strong reasons to suspect that this detainee suffers from chronic mental illness, which is responsible for his behavior and has resulted in serious crimes against the state, with which he is charged."

The prisoner arrives in handcuffs, looking anxious and fearful. At the beginning of his admission report, the forensic psychiatrist takes note of "burning and penetrating eyes, and a Christlike beard."

During the interview the prisoner insists on his right to take notes and to write down the questions asked of him; when this is denied, he refuses to participate in the evaluation interview. On the ward, surrounded by seriously ill offenders, he keeps to himself and is described as "withdrawn, with long staring spells, and persistent refusal to discuss his thoughts and feelings." The ward staff is puzzled by his "excessive attention" to food served in the hospital, and his concern that medication has been put into his food is described in ward notes as "paranoid."

By the end of the first week, the prisoner is demanding to see the medical director of the hospital. When the director obliges, the prisoner confronts him with an accusation of "collaborating in crimes against humanity." The doctor is reminded of the fate of the Nazi doctors during the Nuremberg Trials. The prisoner categorically denies the criminal nature of his activity and claims that he pursued his chosen profession in writing a book about the state economy.

From the information provided by the secret police investigator and summaries of treatment obtained from the local health center and the district mental health clinic, the forensic psychiatrist learns that the patient had a "stormy adolescence," during which he pursued, with abandon, the study of his country's history, literature, and art. He was described by his teachers as "stubborn, oppositional, and obsessed with his ideas." His principal wrote: "This young man is far too sensitive and intense for his age. He is negative about everything our country stands for, and his tastes in art and music are bizarre. However, he is a great mathematician, and with proper guidance and education, he can be an asset to our country."

The records of the local draft board revealed that the prisoner was relieved from compulsory military duty because of a diagnosis of "psychoneurosis" established by a psychiatrist at the district mental health clinic. The records from the clinic described a young man who was "moody, preoccupied with his interest in history and mathematics, precise and compulsive in his habits, with some excessive concern about his health." Apparently, the prisoner was seen at the mental health clinic only three times, and never requested any treatment.

The forensic psychiatrist makes no attempt to contact or interview by telephone, Gregor's wife, parents, or friends and colleagues (he is under strict orders not to reveal the prisoner's whereabouts because of the KGB's insistence on keeping Gregor incommunicado before the trial). Failing to do that, the forensic psychiatrist never learns that the prisoner was a "star student" in the department of economics of a leading state university, or that he was universally admired by his peers and faculty. Most of his professors later became his colleagues, when Gregor was invited to remain in the department to continue his research. The forensic psychiatrist also never learns that the prisoner has written several articles approved for publication in respected professional journals, that he has been married for 18 years, maintains numerous close and enduring friendships, and has adopted two children, after having been approved as an adoptive parent. Finally, the forensic psychiatrist was also denied an opportunity to read Gregor's book, which presumably was a product of a disturbed mind.

By the end of the third week, the prisoner was forcibly given small doses of a neuroleptic. He became weak and apathetic, complained of dryness of the mouth, increased appetite and grogginess throughout the day, and an increasingly troublesome tremor. Each time the prisoner was given medication, he offered resistance. This was described in the record as "paranoid refusal to believe in the good intentions of the medical personnel, and inability to develop insight into his condition and his own needs."

When medication produces no change in the prisoner's attitude except for obvious side effects, it is discontinued. One week after this, the prisoner is looking more cheerful, and finally agrees to cooperate with the expert committee consisting of three forensic psychiatrists. When the committee sees the prisoner, none of its members has a chance to read the manuscript that brought the man to the attention of the authorities. During the interview, the prisoner is attentive and guarded, and later is described by one of the members as "hypervigilant, with obvious ideas of reference." The committee unanimously agrees on the diagnosis offered by the forensic psychiatrist, Sluggish Schizophrenia. (Sluggish Schizophrenia is considered by Soviet authorities to be the mildest form of the continuous subtype of Schizophrenia. It is roughly equivalent to the concepts of "pseudoneurotic" and "pseudopsychopathic" Schizophrenias that were used by clinicians in the United States in previous decades. It is presumed to have a more favorable course than the other types of Schizophrenia.) The committee recommends compulsory psychiatric treatment for Gregor "because of his inability to have a critical attitude toward his own condition and circumstances and failure to cooperate with necessary medical treatment."

Discusssion of "Crimes Against the State"

The Soviet psychiatrist (now living in the United States) who provided this case suggests that the KGB investigator knew that the state would have considerable difficulty in prosecuting Gregor since it would have had to prove that he had a malicious intent to "undermine and harm the interests of the Socialist State." Because Gregor is articulate and persuasive, a public trial would have been an embarrassment to the government. Knowing that Gregor had been given a psychiatric diagnosis that exempted him from the draft, the KGB investigator reasoned that a trial would be unnecessary and that the credibility of Gregor's ideas would be undermined if his behavior could be attributed to a mental disorder.

The forensic psychiatrist was given inadequate and biased information, had no access to his "patient's" family or colleagues, and had to deal with a frightened and unwilling man. Practicing within a social system with an extremely narrow range of "permissible" behavior and within a profession that uses an extraordinarily broad concept of Schizophrenia, the forensic psychiatrist could very well have been sincere in considering Gregor mentally ill. It is also possible that the psychiatrist was cynically using his power to make diagnoses, hospitalize, and treat in order to satisfy an implicit request from the KGB to take this "troublesome man" off their hands.

Whether or not the forensic psychiatrist actually believed that Gregor was ill, he probably justified his diagnosis as follows: The onset of Gregor's Schizophrenia was, as is usual in this illness, at the time of adolescent transition to adult life. He exhibited overvalued ideas, instability of mood, inappropriately intense and single-minded pursuit of interests unusual for boys of his age, and obsessive compulsive personality traits. He developed a system of rationalized obsessive preoccupations with seeking reforms in Soviet society His tragic world view is evidence of chronic dysphoria and anhedonia. His belief that he can make a contribution to the economic theory and well-being of his country is evidence of an overvalued idea that has progressed into a fantastic delusion of reform. His cautious attitude toward authorities and state-appointed physicians is an expression of paranoid and self-referential perception.

In contrast to the Soviet forensic psychiatrist, we see absolutely no justification for making a psychiatric diagnosis in Gregor's case. His difficulties are certainly a result of the interaction between his personality traits and an oppressive society. However, in a freer society these personality traits might not cause any particular difficulties--indeed, might even be rewarded.

DSM-III-R Diagnosis:

Axis I: V71.09 No Diagnosis or Condition
Axis II: V71.09 No Diagnosis or Condition